Management of Foot Ulcers a Priority for Patients with Diabetes

November 03, 2016

NORTH CONWAY, NH – For Dale and Kelly Duguay, of Madison, NH, it was nothing bigger than the head of a pin. What they described as “a tiny hole” in Dale’s foot didn’t seem like a big deal, but given his diagnosis of diabetes, he made an appointment with Memorial Hospital Podiatrist and Wound Care Director Dr. Alan Goldenhar to check it out.

“Dr. Goldenhar identified it as an infection in the bone. He sent me for IV antibiotic treatment which was not successful. Three days after treatment, my foot was two to three times its normal size, red all the way up to my knee,” Dale said.

Dale was soon in a battle to save his foot due to a serious infection, one compounded by his diabetes. Dr. Goldenhar stated, “The reason that diabetics can have problems and develop ulcers quickly is that once you have diabetes for a length of time, you have numbness. You don’t know you have a sore on your foot. You have blunted or total lack of sensation. You can have poor circulation. Wounds that appear won’t heal as readily. Diabetics can have a harder time mounting a response to infection. They can become infected quickly. It’s the evil triad. In Dale’s case it went to something limb threatening in a matter of a day or so.”

An estimated 29.1 million people (9.3 percent of the population) have diabetes, and nearly 28 percent are undiagnosed. In addition, about 86 million US adults have prediabetes and more than 77 million of them are unaware. People with diabetes can also experience co-existing conditions such as stroke, blindness, heart disease, kidney failure and lower-limb amputation.

In 2010, nearly 73,000 adults aged 20 years or older with diagnosed diabetes received non-traumatic lower-limb amputations. Even more alarmingly, people with an amputation have a 50 percent mortality rate within five years. Diabetes related amputations may result from chronic wounds caused by diabetes.

Dale was determined not to give up. Dr. Goldenhar referred him to Memorial’s Emergency Department, where Chris Marvelli, MD was called in to do immediate surgery on his foot. “I ended up having a third of my foot removed,” Dale continued. Still, this was better than total limb amputation, a real possibility given his condition.

Dr. Goldenhar stressed the importance utilizing wound care therapy in order to save a limb. “We try to practice limb salvage because if a diabetic loses a leg there is 50% chance that they’ll lose the other leg within 5 years. If you do get this amputation of your other limb, there’s a 50% chance of death within 5 years. When you lose a limb, you are putting a lot of pressure on the other limb putting it at risk. That’s why you try to save it at all costs. It costs a lot less for a patient to receive wound care then to have them go through an amputation.”

Still, it was tough going for Dale and Kelly. “Nobody thought he was going to keep that foot. They said it was one of the worst foot infections they’d ever seen. Me and Dr. Marvelli were the only ones who thought he would keep it and he was right!” stated Kelly, her husband’s loyal caregiver who was by his side throughout the ordeal.

Dale was hospitalized for 4 days after the surgery. He stated, “(Hospitalist) Dr. Daigle took care of me. Everybody was very professional and caring. They worked hand in hand with the Wound Care staff. They got the right staff involved right away. (Wound Care certified nurse) Becky Gray RN came to see when I was an inpatient.”

After discharge, Dale’s treatment continued with three months of on-going care at Memorial Hospital’s Wound Care Center. He credits his recovery to the use of a “wound vac” – also known as Negative Pressure Wound Therapy, just one of the proper wound care techniques used at Memorial that are imperative to healing diabetic foot ulcers. Other effective techniques at Memorial’s Wound Care Center include Debridement, Offloading or Total Contact Casts (TCC), and Hyperbaric Oxygen Therapy (HBOT). In addition to treatment with the Wound Care Center, Dale also received infusion therapy at Memorial’s Chemotherapy &amp; Infusion Center. They credit the coordination of care between the many practices and services, as well as with Visiting Nurse Home Care of Carroll County, as being integral to his recovery. “It takes a village,” laughed Kelly.

Dr. Goldenhar couldn’t agree more. “We see better outcomes because we have a wound care center. That’s the key. We have an interdisciplinary group who manage all kinds of wounds. We do a comprehensive evaluation. We develop a treatment plan. We meet and discuss patients’ cases every week. It’s a lot of teamwork that goes into it. The key take away is that you cannot effectively take care of a diabetic foot wound without a team approach. You can’t do it alone. Everyone brings something to the table.”

After 5 months of treatment, Dale is on the road to recovery, although still wearing sandals at times for comfort. “I’m walking normally now. I was wheelchair bound for two months. Dr. Goldenhar worked hard to ensure our insurance covered everything. Life is normal again – I don’t need assistance to walk. I do all the things I would normally do – hobbies and activities are resumed.”

He continued, ”I’d like to say a big thank you to Dr. Goldenhar and all of the staff over at the wound care center at Memorial Hospital. Without their knowledge and expertise the healing of my wound may not have turned out as well as it did. Thank you to all.”

Preventing Diabetic Foot Ulcers

Stop smoking immediately

Comprehensive foot examinations each time you visit your healthcare provider (at least four times a year)

Daily self-inspections of the feet, or have a family member perform the inspection

Regular care of the feet including cleaning toenails and taking care of corns and calluses

Choose supportive, proper footwear (shoes and socks)

Take steps to improve circulation such as eating healthier and exercising on a regular basis

Dr. Goldenhar emphasized, “For the diabetic patient, the key to preventing foot wounds is #1 – look at your feet. Seek professional care from a podiatrist. Also good blood sugar control is key. Because if you don’t have control you can have problems with neuropathy, numbness. Stop smoking if you smoke. It effects healing. Look for any cuts, infections, irritations, fungal nails, any break in the skin. If you have a wound, talk to your primary care provider to have your doctor working in concert with us.”

For more information on Wound Care at Memorial Hospital, call 603-356- 4999. For information on the Miranda Center for Diabetes at Memorial Hospital, call 603-356- 0796. Find them online at www.memorialhospitalnh.org.